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Research & Scholarship

Current Research and Scholarly Interests

Our clinical and research interests are dedicated to improving the health and lives of women by breast cancer detection and diagnosis using imaging, in both development and testing of new imaging techniques, and transfer of new technology to the clinical arena.

Stanford provides the optimal location in Silcon Valley for developing, researching, transferring and implementing new technology to the clinical arena in our busy all-digital tomosynthesis Breast Cancer Center. Working with world-class basic science researchers, engineers, chemists and physicists the Stanford Breast Imaging service provides state-of-the-art imaging with access to the latest technologies and imaging modalities. The Lucas Center for Magnetic Resonance and Spectroscopy, and the Clark Center which houses the MIPS program are located within a block from the Medical Center and from each other. Breast cancer imaging research is supported by a uniquely qualified team of Stanford Radiology Engineering, Physics and Medical faculty, postdoctoral candidates and graduate students from around the world. We have demonstrated the effectiveness of this team by our development, transfer and publication of MRI techniques to breast cancer imaging.

The Stanford Breast Imaging service has state-of-the-art imaging equipment to provide imaging research material, including all tomosynthesis digital mammography units with CAD, PACS to correlate ultrasound, MRI and PET/CT images and a hosptial-wide patient electronic medical information system. Research stems from clinical questions generated at the Breast Center, clinical dilmmas encountered during everyday practice, and implemenation of new techniques developed at Stanford and in Silicon Valley to improve women's health.

Clinical Trials

Magnetic Resonance Imaging of Breast CancerRecruiting

To compare magnetic resonance imaging (MRI) with more well established diagnostic imaging
techniques to determine which method best finds and defines breast cancer.

To see if performing breast MRI before a lumpectomy will help the surgeon successfully remove
the entire cancer with normal tissue margins in a single operation thereby reducing the need
for additional surgical procedures. The study will also measure how well MRI can find
unsuspected cancers in the same breast as the known cancer; how well MRI will find
unsuspected cancers in the opposite breast; how often MRI will generate false positive MRI
findings; whether routinely incorporating breast MRI delays care or adds unnecessary cost;
and, whether breast MRI is able to reduce the frequency of cancer recurrence in the treated
breast or elsewhere in the body.

Stanford is currently not accepting patients for this trial.For more information, please contact Sally Bobo, 650-736-1472.

The primary study endpoint -SoftScan adjunctive accuracy- will be used to test the hypothesis
that the adjunctive combination of the SoftScan with x-ray mammography provides diagnostic
accuracy that is significantly better than x-ray mammography alone.

Stanford is currently not accepting patients for this trial.For more information, please contact Leslie Roche, (650) 724 - 5913.

This pilot clinical trial studies the use of the radiofrequency-guided localization in
patients with abnormal breast tissue undergoing lumpectomy (a type of breast-sparing
surgery). The radiofrequency identification localization system consists of an implantable
radiofrequency identification tag and a hand-held radiofrequency reader to mark abnormal
breast tissue before surgery and later surgically retrieve them. Radiofrequency-guided
localization may make it easier to find and remove abnormal breast tissue during lumpectomy.

Stanford is currently not accepting patients for this trial.For more information, please contact Sumita Sood, 650-723-0186.

Breast Density and the Role of Preoperative Mammography, Ultrasound, Elastography and MRINot Recruiting

To determine the sensitivity, specificity, and accuracy of preoperative ultrasound,
elastography, mammography and breast MRI in women with dense breast tissue diagnosed with
breast cancer; to test whether elastography or MRI can improve upon routine mammogram and
conventional ultrasound in women with dense breast tissue.

Stanford is currently not accepting patients for this trial.For more information, please contact Leslie Roche, (650) 724 - 5913.

To determine whether an accelerated course of radiotherapy delivered to the lumpectomy cavity
plus margin using IORT as a single dose, intracavitary brachytherapy with the MammoSite
device over 5 days, partial breast 3-D CRT in 5 days, or stereotactic APBI over 4 days is a
feasible and safe alternative to a six and a half week course of whole breast radiotherapy.
The study will measure both short and long-term complications of radiation treatment, short
and long-term breast cosmesis, local rates of in-breast cancer recurrence, regional
recurrences, distant metastases, and overall survival.

Stanford is currently not accepting patients for this trial.For more information, please contact Sally Bobo, (650) 736 - 1472.

Abstract

To determine whether dynamic contrast enhancement magnetic resonance imaging (DCE-MRI) characteristics of the breast tumor and background parenchyma can distinguish molecular subtypes (ie, luminal A/B or basal) of breast cancer.In all, 84 patients from one institution and 126 patients from The Cancer Genome Atlas (TCGA) were used for discovery and external validation, respectively. Thirty-five quantitative image features were extracted from DCE-MRI (1.5 or 3T) including morphology, texture, and volumetric features, which capture both tumor and background parenchymal enhancement (BPE) characteristics. Multiple testing was corrected using the Benjamini-Hochberg method to control the false-discovery rate (FDR). Sparse logistic regression models were built using the discovery cohort to distinguish each of the three studied molecular subtypes versus the rest, and the models were evaluated in the validation cohort.On univariate analysis in discovery and validation cohorts, two features characterizing tumor and two characterizing BPE were statistically significant in separating luminal A versus nonluminal A cancers; two features characterizing tumor were statistically significant for separating luminal B; one feature characterizing tumor and one characterizing BPE reached statistical significance for distinguishing basal (Wilcoxon P < 0.05, FDR < 0.25). In discovery and validation cohorts, multivariate logistic regression models achieved an area under the receiver operator characteristic curve (AUC) of 0.71 and 0.73 for luminal A cancer, 0.67 and 0.69 for luminal B cancer, and 0.66 and 0.79 for basal cancer, respectively.DCE-MRI characteristics of breast cancer and BPE may potentially be used to distinguish among molecular subtypes of breast cancer.3 J. Magn. Reson. Imaging 2017.

Abstract

To identify novel breast cancer subtypes by extracting quantitative imaging phenotypes of the tumor and surrounding parenchyma, and to elucidate the underlying biological underpinnings and evaluate the prognostic capacity for predicting recurrence-free survival (RFS).We retrospectively analyzed dynamic contrast-enhanced magnetic resonance imaging data of patients from a single-center discovery cohort (n=60) and an independent multi-center validation cohort (n=96). Quantitative image features were extracted to characterize tumor morphology, intra-tumor heterogeneity of contrast agent wash-in/wash-out patterns, and tumor-surrounding parenchyma enhancement. Based on these image features, we used unsupervised consensus clustering to identify robust imaging subtypes, and evaluated their clinical and biological relevance. We built a gene expression-based classifier of imaging subtypes and tested their prognostic significance in five additional cohorts with publically available gene expression data but without imaging data (n=1160).Three distinct imaging subtypes, i.e., homogeneous intratumoral enhancing, minimal parenchymal enhancing, and prominent parenchymal enhancing, were identified and validated. In the discovery cohort, imaging subtypes stratified patients with significantly different 5-year RFS rates of 79.6%, 65.2%, 52.5% (logrank P=0.025), and remained as an independent predictor after adjusting for clinicopathological factors (hazard ratio=2.79, P=0.016). The prognostic value of imaging subtypes was further validated in five independent gene expression cohorts, with average 5-year RFS rates of 88.1%, 74.0%, 59.5% (logrank P from <0.0001 to 0.008). Each imaging subtype was associated with specific dysregulated molecular pathways that can be therapeutically targeted.Imaging subtypes provide complimentary value to established histopathological or molecular subtypes, and may help stratify breast cancer patients.

Abstract

Morbidly obese women are at increased risk for breast cancer, and the majority of surgical weight-loss patients are older than 40 years old.The purpose of the present study was to determine the technical and interpretive changes in mammography following bariatric surgery.Accredited Academic Hospital.Two breast-imaging radiologists reviewed screening mammograms performed on 10 morbidly obese women undergoing bariatric surgery both pre- and postoperatively. American College of Radiology Breast Imaging Reporting and Data System (ACR BI-RADS) density, imaging quality measurements, compression force, breast thickness, pectoral nipple line (PNL) length, and x-ray beam kilovoltage (kVp) and miliamperes per second (mAs) were recorded.The average patient age was 56 years old, with mean age at menarche of 13 years old; 70% of patients were postmenopausal (average age 49 years at menopause) and 50% had a family history of breast cancer. There was a significant reduction in both BMI (-13.2 kg/m(2), P

Abstract

Breast density notification laws, passed in 19 states as of October 2014, mandate that patients be informed of their breast density. The purpose of this study is to assess the impact of this legislation on radiology practices, including performance of breast cancer risk assessment and supplemental screening studies. A 20-question anonymous web-based survey was emailed to radiologists in the Society of Breast Imaging between August 2013 and March 2014. Statistical analysis was performed using Fisher's exact test. Around 121 radiologists from 110 facilities in 34 USA states and 1 Canadian site responded. About 50% (55/110) of facilities had breast density legislation, 36% of facilities (39/109) performed breast cancer risk assessment (one facility did not respond). Risk assessment was performed as a new task in response to density legislation in 40% (6/15) of facilities in states with notification laws. However, there was no significant difference in performing risk assessment between facilities in states with a law and those without (p

Abstract

Accelerated partial breast irradiation (APBI) is emerging as an alternative to whole-breast irradiation. This study presents the results of a prospective trial evaluating 3-dimensional conformal radiotherapy (3D-CRT) to deliver APBI for early-stage breast cancer.Patients with unifocal stage 0-II breast cancer measuring ?2.5 cm without lymph node involvement were eligible. After lumpectomy, 3D-CRT APBI was delivered to the lumpectomy cavity + margin (34-38.5 Gy in 10 fractions over 5 days).141 patients with 143 breast cancers (2 bilateral) were treated with 3D-CRT APBI. Median age was 60. Median tumor size was 1.1 cm. At a median follow up of 60 months (range, 5-113), the 5-year and 8-year cumulative incidence rate of a true recurrence is 0.9%. The 5-year and 8-year cumulative incidence rates of an elsewhere failure are 2.4% and 4.4%, respectively. The 5-year and 8-year overall survival is 100% and 94%, respectively. Among the 62 patients with follow up >5 years, 95% had excellent/good cosmetic results.Our experience with 3D-CRT APBI demonstrates excellent cosmesis and local control. Longer follow up will be necessary to evaluate long-term efficacy and toxicity of 3D-CRT APBI. CLINICALTRIALS.NCT00185744.

Abstract

Resection of biopsy-proven involved axillary lymph nodes (iALNs) is important to reduce the false-negative rates of sentinel lymph node (SLN) biopsy after neo-adjuvant chemotherapy (NAC) in patients with initially node-positive breast cancer. Preoperative wire localization for iALNs marked with clips placed during biopsy is a technique that may help the removal of iALNs after NAC. However, ultrasound (US)-guided localization is often difficult because the clips cannot always be reliably visible on US. Computed tomography (CT)-guided wire localization can be used; however, to date there have been no reports on CT-guided wire localization for iALNs. The aim of this study was to describe a series of patients who received CT-guided wire localization for iALN removal after NAC and to evaluate the feasibility of this technique. We retrospectively analyzed five women with initially node-positive breast cancer (age, 41-52 years) who were scheduled for SLN biopsy after NAC and received preoperative CT-guided wire localization for iALNs. CT visualized all the clips that were not identified on post-NAC US. The wire tip was deployed beyond or at the target, with the shortest distance between the wire and the index clip ranging from 0 to 2.5 mm. The total procedure time was 21-38 minutes with good patient tolerance and no complications. In four of five cases, CT wire localization aided in identification and resection of iALNs that were not identified with lymphatic mapping. Residual nodal disease was confirmed in two cases: both had residual disease in wire-localized lymph nodes in addition to SLNs. Although further studies with more cases are required, our results suggest that CT-guided wire localization for iALNs is a feasible technique that facilitates identification and removal of the iALNs as part of SLN biopsy after NAC in situations where US localization is unsuccessful.

Abstract

Women treated with mantle irradiation for Hodgkin lymphoma (HL) are at an increased risk of developing breast cancer (BC). Current guidelines recommend screening breast magnetic resonance imaging (MRI) as an adjunct to mammography (M) in these patients. There are limited data, however, as to the impact of breast MRI on cancer detection rates. The aim of the current study is to evaluate the use of breast MRI in survivors of HL treated and followed at a single institution.We retrospectively reviewed 980 female patients treated with mantle irradiation for HL between 1961 and 2008. Records were reviewed to determine age at radiotherapy treatment, radiotherapy dose, breast imaging (including M and breast MRI), biopsy results if applicable, and incidence of BC.A total of 118 patients had breast imaging performed at our institution. Median age at HL diagnosis was 28 years (range, 10 to 69 y). Median radiotherapy dose was 36 Gy (range, 20 to 45 Gy). Seventy-nine patients (67%) underwent M screening only, 1 (1%) breast MRI only, and 38 (32%) both M and breast MRI. Of these 38, 19 (50%) underwent 54 screening MRI studies (range per patient=1 to 8), 13 (34%) underwent preoperative MRI for workup of BC, and 6 (16%) initiated screening MRI of the contralateral breast only after diagnosed with BC. Fifty-nine biopsies were performed: 47 were prompted by suspicious M findings only, 10 by palpable findings on physical examination (PE), and 2 by suspicious breast MRI findings. Of the 47 biopsies prompted by M, 24 revealed malignant disease, whereas 23 proved to be benign. All 10 biopsies performed by palpation were malignant. Both biopsies prompted by MRI findings were benign. With M, there were 34 true-positive findings in 32 patients, 23 false-positive findings, and 1 false-negative finding. With screening MRI, there were 2 false-positive findings, 1 false-negative finding, and no true-positive findings.The role of screening breast MRI in women previously irradiated for HL is evolving. Further education of patients and physicians is important to increase awareness of more sensitive BC screening modalities in this high-risk population. Future studies are necessary to determine the appropriate integration of screening breast MRI into the ongoing follow-up of these women.

Abstract

The aim of this study was to measure women's knowledge of breast density and their attitudes toward supplemental screening tests in the setting of the California Breast Density Notification Law at an academic facility and a county hospital, serving women with higher and lower socioeconomic status, respectively.Institutional review board exemptions were obtained. A survey was administered during screening mammography at two facilities, assessing women's awareness of and interest in knowing their breast density and interest in and willingness to pay for supplemental whole breast ultrasound and contrast-enhanced spectral mammography (CEMG). The results were compared by using Fisher exact tests between groups.A total of 105 of 130 and 132 of 153 women responded to the survey at the academic and county facilities, respectively. Among respondents at the academic and county facilities, 23% and 5% were aware of their breast density, and 94% and 79% wanted to know their density. A majority were interested in supplemental ultrasonography and CEMG at both sites; however, fewer women had a willingness to pay for the supplemental tests at the county hospital compared with those at the academic facility (22% and 70%, respectively, for ultrasound, P < .0001; 20% and 65%, respectively, for CEMG, P < .0001).Both groups of women were interested in knowing their breast density and in supplemental screening tests. However, women at the county hospital were less willing to incur out-of-pocket expenses, suggesting a potential for a disparity in health care access for women of lower socioeconomic status after the enactment of breast density notification legislation.

Abstract

Pretreatment evaluation of axillary lymph nodes (ALNs) and marking of biopsied nodes in patients with newly diagnosed breast cancer is becoming routine practice. We sought to test tattooing of biopsied ALNs with a sterile black carbon suspension (Spot?). The intraoperative success of identifying tattooed ALNs and their concordance to sentinel nodes was determined.Women with suspicious ALNs and newly diagnosed breast cancer underwent palpation and/or ultrasound-guided fine needle aspiration or core needle biopsy, followed by injection of 0.1 to 0.5 ml of Spot? ink into the cortex of ALNs and adjacent soft tissue. Group I underwent surgery first, and group II underwent neoadjuvant therapy followed by surgery. Identification of black pigment and concordance between sentinel and tattooed nodes was evaluated.Twenty-eight patients were tattooed, 16 in group I and 12 in group II. Seventeen cases had evidence of atypia or metastases, 8 (50 %) in group I and 9 (75 %) in group II. Average number of days from tattooing to surgery was 22.9 (group I) and 130 (group II). Black tattoo ink was visualized intraoperatively in all cases, except one case with microscopic black pigment only. Fourteen group I and 10 group II patients had black pigment on histological examination of ALNs. Sentinel nodes corresponded to tattooed nodes in all except one group I patient with a tattooed non-sentinel node.Tattooed nodes are visible intraoperatively, even months later. This approach obviates the need for additional localization procedures during axillary staging.

Abstract

Shortwave infrared (SWIR or NIR-II) light provides significant advantages for imaging biological structures due to reduced autofluorescence and photon scattering. Here, we report on the development of rare-earth nanoprobes that exhibit SWIR luminescence following X-ray irradiation. We demonstrate the ability of X-ray-induced SWIR luminescence (X-IR) to monitor biodistribution and map lymphatic drainage. Our results indicate X-IR imaging is a promising new modality for preclinical applications and has potential for dual-modality molecular disease imaging.

Abstract

The objective of this study was to investigate patient and breast MRI characteristics associated with noncompliance with recommended follow-up after MRI-guided core needle biopsy of suspicious breast lesions.A retrospective review was performed of 576 breast lesions biopsied under MRI guidance between 2007 and 2010. Patient follow-up was obtained from the medical record and from contact with referring physicians.Of 415 women who underwent 576 MRI-guided core needle biopsies for suspicious breast lesions, 123 (29.6%) patients representing 154 of 576 (26.7%) lesions were noncompliant with recommended excision or 6-month MRI follow-up. Referring physicians provided information for 63% (97/154) of lesions in noncompliant patients, of which 49.5% (48/97) were followed by mammography instead of excision or MRI. Noncompliance with MRI follow-up was significantly associated with referral for biopsy by outside hospital physicians (odds ratio [OR], 2.40; p = 0.0001) and with referral for screening MRI (1.46; p = 0.093) and biopsy of a focus or foci lesion (1.63; p = 0.088). Among 178 lesions in patients compliant with follow-up MRI after MRI-guided core needle biopsy, 7.9% (14/178) had abnormal follow-up MRI results, half of which (3.9%, 7/178) were found on repeat biopsy to be high-risk or malignant.Institutions performing MRI-guided core biopsies should be aware that patients referred from outside institutions are more likely to be noncompliant with recommended follow-up. Strategies to improve follow-up should include educating patients on the difference between mammography and MRI follow-up.

Abstract

To compare the image quality of three techniques and diagnostic performance in detecting implant rupture.The study included 161 implants for the evaluation of image quality, composed of water-saturated short TI inversion recovery (herein called "water-sat STIR"), three-point Dixon techniques (herein called "Dixon"), and short TI inversion recovery fast spin-echo with iterative decomposition of silicone and water using least-squares approximation (herein called "STIR IDEAL") and included 41 implants for the evaluation of diagnostic performance in detecting rupture, composed of water-sat STIR and STIR IDEAL. Six image quality categories were evaluated and three classifications were used: normal implant, possible rupture, and definite rupture.Statistically significant differences were noted for the image quality categories (p<0.001). STIR IDEAL was superior or equal to water-sat STIR in all image quality categories except artifact effects and superior to Dixon in all categories. Water-sat STIR performed the poorest for water suppression uniformity. The sensitivity and specificity in detecting implant rupture of STIR-IDEAL were 81.8 % and 77.8 % and the difference between two techniques was not statistically significant.STIR-IDEAL is a useful silicone-specific imaging technique demonstrating more robust water suppression and equivalent diagnostic accuracy for detecting implant rupture, than water-sat STIR, at the cost of longer scan time and an increase in minor motion artifacts.

Abstract

BACKGROUND AND PURPOSE: Pre-treatment breast magnetic resonance imaging (MRI) findings in a cohort of women prospectively evaluated for accelerated partial breast irradiation (APBI) are reviewed and characterized to determine the optimal use of MRI in these patients. MATERIALS AND METHODS: Candidates initially deemed eligible for a prospective APBI trial based on physical examination, mammography, and ultrasound (US) were further evaluated with breast MRI before treatment. All abnormal MRI findings were biopsied. RESULTS: Between 2002 and 2011, 180 women who met inclusion criteria for APBI underwent breast MRI prior to treatment (median age=59; range 38-86). 126 tumors (70%) were invasive carcinomas with or without associated DCIS, while 54 (30%) were pure DCIS. Breast MRI confirmed unifocal disease in 109 patients with 111 cancers (60.5% of MRI cohort). Multifocal disease was identified in 19 patients (10.5% of MRI cohort), while multicentric disease was present in 3 patients (1.6% of MRI cohort). Five patients (4%) had an MRI-detected contralateral cancer. False positive MRI findings were seen in 45 patients (25% of MRI cohort). Pre-menopausal patients and patients with tumors >2cm were more likely to have MRI-detected multifocal/multicentric disease. While there was no statistically significant correlation between multifocal/multicentric disease and breast density, tumor histology, grade, ER status, or Her2/Neu expression, numbers in each category were small, suggesting a lack of statistical power to detect differences that may be clinically meaningful. One hundred and fifty-two of the 180 patients (84.4%) successfully completed lumpectomy and APBI, while 6.7% of the cohort underwent mastectomy. CONCLUSIONS: Breast MRI identified additional disease in 12% of APBI candidates. Premenopausal women and patients with tumors >2cm were more likely to have MRI-detected multifocal/multicentric disease.

Abstract

Our aim was to compare the ability of radiologists to detect breast cancers using one-view breast tomosynthesis (BT) and two-view digital mammography (DM) in an enriched population of diseased patients and benign and/or healthy patients.All participants gave informed consent. The BT and DM examinations were performed with about the same average glandular dose to the breast. The study population comprised patients with subtle signs of malignancy seen on DM and/or ultrasonography. Ground truth was established by pathology, needle biopsy and/or by 1-year follow-up by mammography, which retrospectively resulted in 89 diseased breasts (1 breast per patient) with 95 malignant lesions and 96 healthy or benign breasts. Two experienced radiologists, who were not participants in the study, determined the locations of the malignant lesions. Five radiologists, experienced in mammography, interpreted the cases independently in a free-response study. The data were analysed by the receiver operating characteristic (ROC) and jackknife alternative free-response ROC (JAFROC) methods, regarding both readers and cases as random effects.The diagnostic accuracy of BT was significantly better than that of DM (JAFROC: p=0.0031, ROC: p=0.0415). The average sensitivity of BT was higher than that of DM (?90% vs ?79%; 95% confidence interval of difference: 0.036, 0.108) while the average false-positive fraction was not significantly different (95% confidence interval of difference: -0.117, 0.010).The diagnostic accuracy of BT was superior to DM in an enriched population.

Abstract

The aim of the study was to determine the feasibility of using a clinical optical breast scanner with molecular imaging strategies based on modulating light transmission.Different concentrations of single-walled carbon nanotubes (SWNT; 0.8-20.0 nM) and black hole quencher-3 (BHQ-3; 2.0-32.0 µM) were studied in specifically designed phantoms (200-1,570 mm(3)) with a clinical optical breast scanner using four wavelengths. Each phantom was placed in the scanner tank filled with optical matching medium. Background scans were compared to absorption scans, and reproducibility was assessed.All SWNT phantoms were detected at four wavelengths, with best results at 684 nm. Higher concentrations (?8.0 µM) were needed for BHQ-3 detection, with the largest contrast at 684 nm. The optical absorption signal was dependent on phantom size and concentration. Reproducibility was excellent (intraclass correlation 0.93-0.98).Nanomolar concentrations of SWNT and micromolar concentrations of BHQ-3 in phantoms were reproducibly detected, showing the potential of light absorbers, with appropriate targeting ligands, as molecular imaging agents for clinical optical breast imaging.

Abstract

The purpose of the present study was to compare the diagnostic accuracy of dual-view digital mammography (DM), single-view breast tomosynthesis (BT) and BT combined with the opposite DM view. Patients with subtle lesions were selected to undergo BT examinations. Two radiologists who are non-participants in the study and have experience in using DM and BT determined the locations and extents of lesions in the images. Five expert mammographers interpreted the cases using the free-response paradigm. The task was to mark and rate clinically reportable findings suspicious for malignancy and clinically relevant benign findings. The marks were scored with reference to the outlined regions into lesion localization or non-lesion localization, and analysed by the jackknife alternative free-response receiver operating characteristic method. The analysis yielded statistically significant differences between the combined modality and dual-view DM (p < 0.05). No differences were found between single-view BT and dual-view DM or between single-view BT and the combined modality.

Abstract

The Breast Imaging Reporting and Data System (BI-RADS) initiative, instituted by the ACR, was begun in the late 1980s to address a lack of standardization and uniformity in mammography practice reporting. An important component of the BI-RADS initiative is the lexicon, a dictionary of descriptors of specific imaging features. The BI-RADS lexicon has always been data driven, using descriptors that previously had been shown in the literature to be predictive of benign and malignant disease. Once established, the BI-RADS lexicon provided new opportunities for quality assurance, communication, research, and improved patient care. The history of this lexicon illustrates a series of challenges and instructive successes that provide a valuable guide for other groups that aspire to develop similar lexicons in the future.

Abstract

The main purpose was to compare breast cancer visibility in one-view breast tomosynthesis (BT) to cancer visibility in one- or two-view digital mammography (DM). Thirty-six patients were selected on the basis of subtle signs of breast cancer on DM. One-view BT was performed with the same compression angle as the DM image in which the finding was least/not visible. On BT, 25 projections images were acquired over an angular range of 50 degrees, with double the dose of one-view DM. Two expert breast imagers classified one- and two-view DM, and BT findings for cancer visibility and BIRADS cancer probability in a non-blinded consensus study. Forty breast cancers were found in 37 breasts. The cancers were rated more visible on BT compared to one-view and two-view DM in 22 and 11 cases, respectively, (p < 0.01 for both comparisons). Comparing one-view DM to one-view BT, 21 patients were upgraded on BIRADS classification (p < 0.01). Comparing two-view DM to one-view BT, 12 patients were upgraded on BIRADS classification (p < 0.01). The results indicate that the cancer visibility on BT is superior to DM, which suggests that BT may have a higher sensitivity for breast cancer detection.

Abstract

To assess which specific morphologic features, enhancement patterns, or pharmacokinetic parameters on breast Magnetic Resonance Imaging (MRI) could predict a false-negative outcome of Proton MR Spectroscopy ((1)H MRS) exam in patients with invasive breast cancer. Sixteen patients with invasive ductal carcinoma of the breast were prospectively included and underwent both, contrast-enhanced breast MRI and (1)H MRS examination of the breast. The MR images were reviewed and the lesions morphologic features, enhancement patterns and pharmacokinetic parameters (k21-value) were scored according to the ACR BI-RADS-MRI lexicon criteria. For the in vivo MRS studies, each spectrum was evaluated for the presence of choline based on consensus reading. Breast MRI and (1)H MRS data were compared to histopathologic findings. In vivo (1)H MRS detected a choline peak in 14/16 (88%) cancers. A false-negative (1)H MRS study occurred in 2/16 (14%) cancer patients. K21 values differed between both groups: the 14 choline positive cancers had k21 values ranging from 0.01 to 0.20/second (mean 0.083/second), whereas the two choline-negative cancers showed k21 values of 0.03 and 0.05/second, respectively (mean 0.040/second). Also enhancement kinetics did differ between both groups; typically both cancers that were choline-negative showed a late phase plateau (100%), whereas this was only shown in 5/14 (36%) of the choline positive cases. There was no difference between both groups with regard to morphologic features on MRI. This study showed that false-negative (1)H MRS examinations do occur in breast cancer patients, and that the presence of a choline peak on (1)H MRS as malignancy marker is related to the k21 value of the invasive tumor being imaged.

Abstract

Treatment regimens for Hodgkin's disease (HD) that have included radiation to lymph node regions in the thorax have contributed to high rates of long-term disease-free survival. However, incidental radiation exposure of breast tissue in young women has significantly increased the risk of breast cancer compared to expected rates in the general population. After informing patients about risks associated with previous treatment of HD, we studied screening mammograms and call-back rates in women at increased risk for developing breast cancer at a younger age. We contacted by mail a cohort of 291 women between 25 and 55 years of age who had received thoracic irradiation before 35 years of age for HD with or without chemotherapy. Subjects were offered information about risks identified after HD therapy with questionnaires to assess response to this information. Ten patients refused participation, 93 did not respond, and 21 were excluded after they reported a prior diagnosis of invasive (1) or in situ (2) breast cancer. One hundred and sixty seven women received information about secondary breast cancer risk and were advised to initiate or maintain mammographic screening. Available mammograms were reviewed by two radiologists and classified according to the ACR BI-RADS Mammography Lexicon. Abnormal findings were correlated to pathology results from biopsies. One hundred and fifteen subjects reported that they obtained new mammograms during the period of the study. Ninety-nine were available for secondary review. Patients were studied an average of 16.9 years after HD treatment (Range: 4.5-32.5 years) at an average of 41 years of age (range 25-55 years). High density breast tissue was identified in 60% (60/99). Seventeen of the women (17.2%) were recalled for further imaging. This was more common in women with heterogeneously dense breast tissue. Seven of those recalled (41%) were advised to undergo biopsies that identified ductal carcinoma in situ (DCIS) in one and benign findings in the others. Among 16 women whose mammograms were unavailable for review, three were diagnosed with DCIS; two of these had microscopic evidence of invasive breast cancer. The four in situ or microinvasive cancers were diagnosed in the study participants at 25-40 years of age and from 5 to 23 years after HD therapy. Biopsies were performed because mammograms detected microcalcifications without palpable abnormality in three of these cases. Women who have had thoracic nodal irradiation for Hodgkin's disease have an increased risk of developing secondary breast cancer at an unusually young age. As expected in younger women, high density breast tissue was common on mammography, and the recall and biopsy rates were unusually high. However, early mammographic screening facilitated diagnosis of in situ and early invasive cancer in 3.5% of our subjects.

Abstract

The ACR and the Society of Breast Imaging have revised the curriculum for resident and fellow education in breast imaging on the basis of substantial changes in breast imaging practice since the initial curriculum was published in 2000. This curriculum provides guidance to academic chairs, residency program directors, and academic section chiefs in assessing and improving their residency and fellowship training programs and indicates to residents and breast imaging fellows the topics they need to learn and the experience they should try to acquire during their training. Radiologists already in practice also may find the curriculum useful in outlining the material they need to know to remain up to date in the practice of breast imaging.

Abstract

Magnetic resonance imaging (MRI) can detect clinically and mammographically occult breast lesions. In this study we report the results of MRI-guided needle localization of suspicious breast lesions by using a freehand technique. Preoperative MRI-guided single-needle localization was performed in 220 patients with 304 MRI-only breast lesions at our hospital between January 1997 and July 2004. Procedures were performed in an open 0.5-T Signa-SP imager allowing real-time monitoring, with patient in prone position, by using a dedicated breast coil. MRI-compatible hookwires were placed in a noncompressed breast by using a freehand technique. MRI findings were correlated with pathology and follow-up. MRI-guided needle localization was performed for a single lesion in 150 patients, for two lesions in 56 patients, and for three lesions in 14 patients. Histopathologic analysis of these 304 lesions showed 104 (34%) malignant lesions, 51 (17%) high-risk lesions, and 149 (49%) benign lesions. The overall lesion size ranged from 2.0-65.0 mm (mean 11.2 mm). No direct complications occurred. Follow-up MRI in 54 patients showed that two (3.7%) lesions were missed by surgical biopsy. MRI-guided freehand needle localization is accurate and allows localization of lesions anterior in the breast, the axillary region, and near the chest wall.

Abstract

Women with inherited BRCA1/2 mutations are at high risk for breast cancer, which mammography often misses. Screening with contrast-enhanced breast magnetic resonance imaging (MRI) detects cancer earlier but increases costs and results in more false-positive scans.To evaluate the cost-effectiveness of screening BRCA1/2 mutation carriers with mammography plus breast MRI compared with mammography alone.A computer model that simulates the life histories of individual BRCA1/2 mutation carriers, incorporating the effects of mammographic and MRI screening was used. The accuracy of mammography and breast MRI was estimated from published data in high-risk women. Breast cancer survival in the absence of screening was based on the Surveillance, Epidemiology and End Results database of breast cancer patients diagnosed in the prescreening period (1975-1981), adjusted for the current use of adjuvant therapy. Utilization rates and costs of diagnostic and treatment interventions were based on a combination of published literature and Medicare payments for 2005.The survival benefit, incremental costs, and cost-effectiveness of MRI screening strategies, which varied by ages of starting and stopping MRI screening, were computed separately for BRCA1 and BRCA2 mutation carriers.Screening strategies that incorporate annual MRI as well as annual mammography have a cost per quality-adjusted life-year (QALY) gained ranging from less than 45,000 dollars to more than 700,000 dollars, depending on the ages selected for MRI screening and the specific BRCA mutation. Relative to screening with mammography alone, the cost per QALY gained by adding MRI from ages 35 to 54 years is 55,420 dollars for BRCA1 mutation carriers, 130,695 dollars for BRCA2 mutation carriers, and 98,454 dollars for BRCA2 mutation carriers who have mammographically dense breasts.Breast MRI screening is more cost-effective for BRCA1 than BRCA2 mutation carriers. The cost-effectiveness of adding MRI to mammography varies greatly by age.

Abstract

Traditional imaging for the diagnosis and staging of breast cancer has relied on the tissue morphology of cancers in the background of normal patterns of fibroglandular breast tissue. X-ray mammography and ultrasound have been the primary modalities for the diagnosis and the work-up of breast cancer. New modalities have been validated including magnetic resonance imaging (MRI) and positron emission tomography (PET). New pulse sequences in MRI combined with contrast enhancement kinetic perfusion curves have greatly enhanced detection of mammographically occult cancers. New modalities on the horizon include optical imaging, exploiting again the differential perfusion properties of cancers in a background of normal glandular tissue. Even more specificity can be ach eved with the addition of ductal or intravenous introduction of optical probes specific to tumor associated antigens such as the HER-2/neu receptor in aggressive breast cancers. Quantum dots and other fluorescent dyes coupled to peptides or other probes will greatly enhance our ability to detect cancers earlier and without ionizing radiation.

Abstract

Clinical breast-imaging tests must be fast, sensitive, specific, add information not otherwise available to clinicians at a reasonable cost, and be biopsy-capable. Mammography, breast ultrasound and imaging guided breast core biopsies and preoperative needle localizations are most often used in breast imaging facilities around the world. This article will describe mammography and breast ultrasound in current clinical practice for breast cancer detection, diagnosis, staging, image-guided biopsy, and for evaluation of response to neoadjuvant chemotherapy.

Abstract

To identify morphologic and dynamic enhancement magnetic resonance imaging (MRI) features of pure ductal carcinoma in situ (DCIS) by using a new intensity-modulated parametric mapping technique, and to correlate the MRI features with histopathologic findings.Fourteen patients with pure DCIS on pathology underwent conventional mammography and contrast-enhanced (CE) MRI using the intensity-modulated parametric mapping technique. The MR images were reviewed and the lesions were categorized according to morphologic and kinetic criteria from the ACR BI-RADS-MRI Lexicon, with BI-RADS 4 and 5 lesions classified as suspicious.With the use of a kinetic curve shape analysis, MRI classified seven of 14 lesions (50%) as suspicious, including four with initial-rapid/late-washout and three with initial-rapid/late-plateau. Using morphologic criteria, MRI classified 10/14 (71%) as suspicious, with the most prominent morphologic feature being a regional enhancement pattern. Using the intensity modulated parametric mapping technique, MRI classified 12/14 cases (86%) as suspicious. Parametric mapping identified all intermediate- and high-grade DCIS lesions.The intensity-modulated parametric mapping technique for breast MRI resulted in the highest detection rate for the DCIS cases. Furthermore, the parametric mapping technique identified all intermediate- and high-grade DCIS lesions, suggesting that a negative MRI using the parametric mapping technique may exclude intermediate- and high-grade DCIS. This finding has potential clinical implications.

Abstract

To prospectively assess the effect of computer-aided detection (CAD) on screening mammogram interpretation in an academic medical center to determine if the outcome is different than that previously reported for community practices.Institutional review board approval was granted, and informed consent was waived. During a 19-month period, 8682 women (median age, 54 years; range, 33-95 years) underwent screening mammography. Each mammogram was interpreted by one of seven radiologists, followed by immediate re-evaluation of the mammogram with CAD information. Each recalled case was classified as follows: radiologist perceived the finding and CAD marked it, radiologist perceived the finding and CAD did not mark it, or CAD prompted the radiologist to perceive the finding and recall the patient. Lesion type was also recorded. Recalled patients were tracked to determine the effect of CAD on recall and biopsy recommendation rates, positive predictive value (PPV) of biopsy, and cancer detection rate. A 95% confidence interval was calculated for cancer detection rate. Pathologic examination was performed for all cancers.Of 8682 patients, 863 (9.9%) with 960 findings were recalled for further work-up (Breast Imaging Reporting and Data System category 0). After further diagnostic imaging, it was recommended that biopsy or aspiration be performed for 181 of 960 findings (19%); 165 interventions were confirmed to have been performed. Twenty-nine cancers were found in this group, with a PPV for biopsy of 18% (29 of 165 findings) and a cancer detection rate of 3.3 per 1000 screening mammograms (29 of 8682 patients). CAD-prompted recalls contributed 8% (73 of 960 findings) of total recalled findings and 7% (two of 29 lesions) of cancers detected. Of 29 cancers (59%), 17 manifested as masses and 12 (41%) were microcalcifications. Ten (34%) cancers were ductal carcinoma in situ, and the remaining cancers had an invasive component. Both cancers found with CAD manifested as masses, and both were invasive ductal carcinoma.Prospective clinical use of CAD in a university hospital setting resulted in a 7.4% increase (from 27 to 29) in cancers detected. Both cancers were nonpalpable masses.

Abstract

The objective of this study was to identify magnetic resonance imaging (MRI) characteristics of fibrocystic change (FCC) of the breast.Fourteen patients with a histopathologic diagnosis of solitary FCC of the breast underwent x-ray mammography and MRI of the breast. Three experienced breast imaging radiologists retrospectively reviewed the MRI findings and categorized the lesions on morphologic and kinetic criteria according to the ACR BI-RADS-MRI Lexicon.The most striking morphologic feature of fibrocystic change was nonmass-like regional enhancement found in 6 of 14 (43%) FCC lesions. Based on morphologic criteria alone, 12 of 14 (86%) lesions were correctly classified as benign. According to analysis of the time-intensity curves, 10 of 14 (71%) FCC lesions were correctly classified as benign.Although FCC has a wide spectrum of morphologic and kinetic features on MRI, it most often presents as a mass or a nonmass-like regional enhancing lesion with benign enhancement kinetics.

Abstract

We performed this study to determine rates of close or transected cancer margins after magnetic resonance imaging-guided bracket wire localization for nonpalpable breast lesions.Of 243 women undergoing MRI-guided wire localizations, 26 had MRI bracket wire localization to excise either a known cancer (n = 19) or a suspicious MRI-detected lesion (n = 7). We reviewed patient age, preoperative diagnosis, operative intent, mammographic breast density, MRI lesion size, MRI enhancement curve and morphology, MRI Breast Imaging Reporting and Data System (BI-RADS) assessment code, number of bracket wires, and pathology size. We analyzed these findings for their relationship to obtaining clear margins at first operative excision.Twenty-one of 26 (81%) patients had cancer. Of 21 patients with cancer, 12 (57%) had negative margins at first excision and 9 (43%) had close/transected margins. MRI size > or = 4 cm was associated with a higher reexcision rate (7 of 9, 78%) than those < 4 cm (2 of 12, 17%) (p = 0.009). MRI BI-RADS score, enhancement curve, morphology, and preoperative core biopsy demonstrating ductal carcinoma in situ (DCIS) were not predictive of reexcision. The average number of wires used for bracketing increased with lesion size, but was not associated with improved outcomes. On pathology, cancer size was smaller in patients with negative margins (12 patients, 1.2 cm) than in those with close/transected margins (9 patients, 4.6 cm) (p < 0.001). Reexcision was based on close/transected margins involving DCIS alone (6, 67%), infiltrating ductal carcinoma and DCIS (2, 22%), or infiltrating ductal carcinoma alone (1, 11%). Reexcision pathology demonstrated DCIS (3, 33%), no residual cancer (5, 55%), and 1 patient was lost to followup (1, 11%). Interestingly, cancer patients who required reexcision were younger (p = 0.022), but breast density was not associated with reexcision.To our knowledge, this is the first report of MRI-guided bracket wire localization. Patients with MRI-detected lesions less than 4 cm had clear margins at first excision; larger MRI-detected lesions were more likely to have close/transected margins. Reexcision was often because of DCIS and was the only pathology found at reexcision, perhaps because MRI is more sensitive for detecting invasive carcinoma than DCIS.

Abstract

The purpose of this study was to assess the utility of contrast-enhanced breast magnetic resonance imaging (MRI) in identifying lesions unidentified on the craniocaudal projection. The authors reviewed five patients with suspicious mammographic lesions not imaged on the craniocaudal mammogram who were referred for contrast-enhanced MRI and underwent subsequent preoperative needle localization in four of the five cases. Five patients, ages 56 to 69 years, had suspicious lesions identified on mediolateral oblique (MLO) or mediolateral (ML) projections only. Ultrasound did not identify the lesion in any of these cases. MRI identified suspicious breast lesions measuring 5 to 12 mm in size. These were located high on the chest wall or in the upper inner quadrant. Suspicious lesions seen only on the MLO or ML projections may reside high on the chest wall or in the upper inner quadrant. Lesions in these locations may be typically excluded on the craniocaudal projection during mammography. Breast MRI has the advantage of imaging the entire breast and is particularly useful for these lesions. In this series, MRI prevented delay in breast cancer diagnosis.

Abstract

To evaluate, by using a computer-aided detection (CAD) program, the nonspecific findings on normal screening mammograms obtained in women in whom breast cancer was later detected at follow-up screening mammography.Four hundred ninety-three mammogram pairs-an initial negative screening mammogram and a subsequently obtained screening mammogram showing cancer-were collected. The mean interval between examinations was 14.6 months. In 169 cases, in which 172 cancers were later depicted, findings on the initial mammogram were subtle enough that either none or only one or two of five blinded radiologists recommended screening recall. On the initial negative mammograms, of the 172 areas where cancer later developed, 137 (80%) had subtle nonspecific findings and were retrospectively judged as having a benign or normal appearance. The mammograms with these subtle findings were evaluated with a commercially available CAD program, and the numbers of CAD marks on these nonspecific findings were analyzed.Of the 172 cancers, 129 (75%) were invasive and 43 (25%) were ductal carcinoma in situ. The CAD program marked 72 (42%) of the 172 findings that subsequently developed into cancer: 24 (29%) of 82 findings recalled by none, 25 (49%) of 51 findings recalled by one, and 23 (59%) of 39 findings recalled by two of the five radiologists. Among the 137 areas with nonspecific normal or benign findings, 41 (30%) areas where cancer subsequently developed were marked by the CAD program.A subset of cancers have perceptible but nonspecific mammographic findings that may be marked by a CAD program, even when the findings do not warrant recall as judged at blinded and unblinded radiologist review. The authors believe failure to act on such nonspecific but CAD-marked findings prospectively does not constitute interpretation below a reasonable standard of care.

Abstract

Phantom and in vitro studies were performed to evaluate the potential application of digital circular tomosynthesis in imaging of the breast and upper cervical spine. A prototype volumetric x-ray system was used to image a mammographic phantom, a fresh mastectomy specimen, and a head phantom containing the upper cervical spine. Results show that breast tissue visualization is improved by the ability to produce sectional images that blur overlying structures and yield three-dimensional information about calcification clusters. In upper cervical spine imaging, digital circular tomosynthesis effectively blurs overlying jaw and skull structures so that C1 and C2 can be visualized in a standard anteroposterior view.

Abstract

To retrospectively review nonspecific findings on prior screening mammograms to determine what features were most often deemed normal or benign despite the development of breast cancer in the same location detected at follow-up screening.Four hundred ninety-three pairs of consecutive mammographic findings were collected from 13 institutions, consisting of initial normal screening findings and a subsequent finding of cancer at screening (mean interval between examinations, 14.6 months). One designated radiologist reviewed each pair of mammograms and determined that 286 findings were judged visible at prior examination in locations where cancer later developed. Five blinded radiologists independently reviewed the prior findings in these 286 cases, identifying 169 mammograms (172 cancers) with findings so subtle that none or only one or two of the five radiologists recommended screening recall. Two unblinded radiologists reviewed the initial and subsequent findings and recorded descriptors and assessments for each finding and subjective factors influencing why, although the lesion was perceptible, it might have been undetected or not recalled.Of 172 cancers, 129 (75%) were invasive (112 T1 tumors and 17 T2 tumors or higher; median diameter, 10 mm), and 43 (25%) were ductal carcinoma in situ (median size, 10 mm). On the prior mammograms, 80% (137 of 172) of these cancers had subtle nonspecific findings where cancer later developed, and most were assessed as being normal or benign in appearance.There is a subset of cancers that display perceptible but nonspecific mammographic findings that do not warrant recall, as judged by both a majority of blinded radiologists and by unblinded reviewers. We believe failure to act on these nonspecific findings prospectively does not necessarily constitute interpretation below a reasonable standard of care.

Abstract

To determine if a subset of atypical ductal hyperplasia (ADH) lesions diagnosed at 11-gauge, directional, vacuum-assisted, prone, stereotactic biopsy fit the "probably benign" definition of a less than 2% chance of being carcinoma at subsequent surgical excision.Clinical, mammographic, and stereotactic biopsy features in 104 consecutive nonpalpable ADH lesions were correlated with the presence of carcinoma at lumpectomy. The results were analyzed with chi(2) statistic, with P

Abstract

Breast magnetic resonance imaging (MRI) screening has been shown to detect early breast cancer. The main challenge ahead for breast MRI screening is to prove its effectiveness in reducing breast cancer mortality. While this challenge is commonly viewed as a scientific, technological, and clinical one, it also carries ethical components. This article is concerned with the risks and benefits of MRI screening that should be explained to screening participants and discusses the evidence needed by policy makers who ultimately will determine a just allocation of health care resources to MRI breast cancer screening.

Abstract

To compare patients with visualized sentinel lymph nodes (SLNs) and patients with nonvisualized SLNs, with a focus on variables affecting SLN visualization at preoperative lymphoscintigraphy and on nodal drainage basins as related to tumor location.One hundred thirty-six patients who had breast cancer underwent preoperative lymphoscintigraphy before SLN biopsy. Patients with visualized and nonvisualized SLNs were compared for age; tumor site, size, and histologic findings; injection guidance method; diagnostic biopsy type; interval between biopsy and lymphoscintigraphy; intraoperative identification method; and surgical identification rate. Visualized SLN drainage basins were noted.Ninety-nine patients had visualized and 37 had nonvisualized SLNs, without statistically significant differences in tumor site, size, and histologic findings; injection guidance method; diagnostic biopsy type; and interval between biopsy and lymphoscintigraphy. Ninety-nine (73%) of the 136 SLNs were visualized at lymphoscintigraphy; 30 (81%) of the 37 nonvisualized SLNS were identified at surgery. Of the seven SLNs not identified at surgery, five were mapped with radiocolloid only. Patients with nonvisualized SLNs were older than those with visualized SLNs. Eleven (46%) of 24 tumors with internal mammary drainage were in the outer part of the breast.Patients with and those without visualization differed in age, SLN identification at surgery, and surgical identification method. Nonvisualized status does not preclude axillary metastasis. In older patients with nonvisualized SLNs, blue dye may aid in SLN detection, as compared with isotope-only localization.

Abstract

The lack of reliable methods for minimally invasive biopsy of suspicious enhancing breast lesions has hindered the utilization of contrast-enhanced magnetic resonance imaging (MRI) for the detection and diagnosis of breast cancer. In this study, a freehand method was developed for large-gauge core needle biopsy (LCNB) guided by intraprocedural MRI (iMRI). Twenty-seven lesions in nineteen patients were biopsied using iMRI-guided LCNB without significant complications. Diagnostic tissue was obtained in all cases. Nineteen of the 27 lesions were subsequently surgically excised. Histopathologic analysis confirmed that iMRI-guided LCNB correctly distinguished benign lesions from malignancy in 18 of the 19 lesions. The histology revealed by core biopsy was partially discrepant with surgical biopsy in 2 of the other 19 lesions. Freehand iMRI-guided LCNB of enhancing breast lesions is promising. Larger studies are needed to determine the smallest lesion that can be sampled reliably and to precisely measure the accuracy of iMRI-guided LCNB as a minimally invasive tool to diagnose suspicious lesions found by breast MRI. J. Magn. Reson. Imaging 2001;13:896-902.

Abstract

Ductal Carcinoma In Situ (DCIS) is the earliest form of ductal cancer, with a high rate of care if treated early. This article outlines the use of breast imaging in DCIS diagnosis, including mammography, MR imaging, and nuclear medicine studies. While MR imaging and nuclear medicine show great promise in DCIS diagnosis, mammography remains the mainstay of DCIS detection by the presence of microcalcifications in early tumors on the mammogram.

Abstract

Given the wide variety of terms for abnormal findings on contrast-enhanced breast MR imaging studies, the United States Public Health Services' Office on Women's Health, the Susan G. Komen Foundation for Breast Cancer Research, and the American College of Radiology, funded a committee (or "working group") of international experts to develop a standard language for breast MR imaging reporting. During the last three years, the group members have developed a preliminary Breast MR Imaging Lexicon to describe abnormal contrast-enhancing findings in the breast on MR imaging studies, with a special focus on lesion morphology on high-resolution scans and kinetic curve data descriptions. The initial version of the Breast MR Imaging Lexicon has undergone preliminary testing and is undergoing further development and refinement based on test results. Future work on the new Breast MR Imaging Lexicon includes continued lexicon development, accumulation of a breast MR imaging case set for lexicon testing, and planning for subsequent education for general radiologists on the new lexicon.

Abstract

Microcalcifications discovered by mammography require careful analysis, occasionally leading to core biopsy to exclude associated breast cancer. We report unrecognized milk of calcium layering on small field of view prone digital stereotactic images. We illustrate important features on prone digital images attributed to milk of calcium which can exclude breast neoplasm, suggest this diagnosis, and prevent unnecessary biopsy.

Abstract

Contrast material-enhanced magnetic resonance (MR) imaging of the breast has variable specificity for differentiation of breast cancer from other enhancing conditions. Two principal strategies to improve its specificity are rapid dynamic MR imaging and high-spatial-resolution MR imaging. A method was developed of combining contemporaneously acquired dynamic and high-spatial-resolution MR imaging data into a single integrated display. Whole-breast rapid dynamic data were condensed into a color map by using pharmacokinetic analysis. The pharmacokinetic results were combined with the high-spatial-resolution images with a new technique that preserves underlying morphologic details. This new method was evaluated by five radiologists for eight breast lesions, and the results were compared with those of the standard method of overlaying parametric map data. The radiologists' ratings showed a statistically significant preference for the intensity-modulated parametric map display method over the overlaid parametric display method for 10 of the 12 evaluation criteria. The new method enabled simultaneous visualization of pharmacokinetic and morphologic information, facilitated assessment of lesion extent, and improved the suppression of noise in the pharmacokinetic data. The ability to simultaneously assess both dynamic and high-spatial-resolution features may ultimately improve the specificity of breast MR imaging.

Abstract

Histological evaluation of the first draining lymph node (sentinel node) in the axilla of patients with breast cancer has dramatically altered the surgical approach to these patients, with sparing of the axilla if no tumour cells are identified. In a fraction of patients imaged after peri-tumoural injection of the breast, there is no visualization of the sentinel node. We retrospectively analysed the status of patients whose nodes were visualized and of patients whose nodes failed to visualize, to define the variables associated with non-visualization of the sentinel node. Seventy-four breast cancer patients were imaged following peri-tumoural injection of filtered 99Tc(m)-sulfur colloid, immediately and up to 5.5 h post-injection. The scintigraphic data were analysed with reference to the patient's age, histology, grade, site and size of tumour, previous diagnostic procedure and time interval to scan, using univariate analysis and a logistic regression model. A sentinel node was visualized in 53 of 74 women (72%). Comparison of patients with non-visualized versus visualized sentinel nodes disclosed no statistically significant univariate relation to age of the patients (P = 0.10), size of tumour (P = 0.46), site (P = 0.26), histology [invasive ductal carcinoma in 16 of 20 (80%) non-visualized cases, and in 43 of 53 (81%) visualized patients], prior excision biopsy (P = 0.36) and time interval to surgery (P = 0.29). Tumour grade was the only significant variable on univariate analysis (P = 0.03), though multivariate analysis showed that none of the independent parameters were statistically significant. In 39 patients with an upper outer quadrant tumour, the location of the sentinel node was not limited to the axilla and even crossed the midline of the breast. Our results show that none of the independent variables is associated with non-visualization of sentinel lymph node on preoperative lymphoscintigraphy of patients with breast cancer, though the tumour grade may have contributed to non-visualization of this node. The non-axillary drainage from upper outer quadrant tumours suggests the routine use of lymphoscintigraphy prior to axillary dissection.

Abstract

Magnetic resonance imaging (MRI) is well suited to the investigation of breast cancer by virtue of its noninvasive nature and its multiplanar imaging abilities. MRI investigations showed high sensitivity but modest specificity for breast cancer detection and diagnosis. Most early studies tested the ability of MRI to evaluate and diagnose findings in the breast discovered by other imaging tests or by breast physical examination (1-4). When it was discovered that MRI identified small breast cancers undetected by mammography or breast ultrasound, MRI was used to estimate breast cancer extent in known cancer cases for surgical planning (5,6). These investigations led to the use of MRI in a multitude of breast imaging applications, raising further questions about the use of MRI in everyday practice: What are the indications for breast MRI in general practice? What is its role in light of other imaging tests? What are its benefits and limitations in each setting? How do I report these studies? The purpose of this article is to review the clinical background regarding indications for the use of MRI and relevant cases in which MRI can impact patient management in breast disease, and to describe new developments in reporting breast MRI studies. J. Magn. Reson. Imaging 2000;12:975-983.

Abstract

A 33-year-old woman with a strong family history of breast cancer who was referred for mammography 5 weeks after completing lactation was found to have new diffuse bilateral microcalcifications in the breast ducts. Contrast material-enhanced magnetic resonance imaging of the breast showed bilateral patchy areas of abnormal enhancement. Large-core needle biopsy showed diffuse calcifications within expanded benign ducts in a background of lactational change, without evidence of malignancy. To the authors' knowledge, these calcifications have not been previously reported and are possibly related to milk stasis or apoptosis associated with lactation.

Abstract

A recently developed Society of Breast Imaging curriculum for residency training is intended to provide guidance to residents and their mentors, and to practicing radiologists who want to keep up to date in screening, diagnosis, and interventional procedures. The curriculum contains lists of key concepts in 14 subject areas: epidemiology; anatomy; pathology, and physiology; equipment and technique; quality control; interpretation; problem-solving mammography; ultrasound; interventional procedures; reporting and medicolegal aspects; screening; MR imaging; therapeutic considerations; and patient management principles. The curriculum also makes recommendations about residency training, including the number of examinations the resident should interpret, and the time the resident should spend in breast imaging. Recommendations for fellowship training are also discussed.

Abstract

Spectral/spatial spin-echo pulses with asymmetric excitation profiles were incorporated into a PRESS-based localization sequence to provide lipid suppression while retaining a sufficient amount of water to allow for correction of motion-induced shot-to-shot phase variations. 1H magnetic resonance spectroscopy data were acquired at 1.5 Tesla from a motion phantom and in vivo from the human liver, kidney, and breast. The results demonstrated that lipids in the chemical shift stopband were completely suppressed and that full metabolite signal intensity was maintained after implementation of a regularization algorithm based on phasing the residual water signal. Liver and kidney spectra contained a large resonance at 3.2 ppm that was ascribed to trimethylammonium moieties (betaine plus choline) and a weaker signal at 3.7 ppm that may result from glycogen. A breast spectrum from a histologically proven invasive ductal carcinoma displayed a highly elevated choline signal (3.2 ppm) relative to that from a normal volunteer.

Abstract

The purpose of the study was to determine the sensitivity and specificity of various morphologic criteria in distinguishing malignant from benign breast lesions using a new sequence (3DSSMT) performed immediately after dynamic breast MRI. 3DSSMT combines a water-selective spectral-spatial excitation and an on-resonance magnetization transfer pulse with three-dimensional spoiled gradient-echo imaging. Morphologic features of 87 pathologically confirmed lesions were analyzed. The presence of either skin thickening, or a combination of a spiculated or microlobulated border, with a rim, ductal, linear, or clumped enhancement pattern was 94% specific and 54% sensitive for malignancy. Conversely, the presence of either a perfectly smooth border, a well-defined margin, non-enhancing internal septations, or a macrolobulated border was 97% specific and 35% sensitive for a benign diagnosis. In conclusion, delayed 3DSSMT discriminates a significant number of benign and malignant breast lesions; it has the potential to improve the diagnostic accuracy of dynamic breast MRI.

Abstract

The objective of this study was to evaluate the relative efficacies of magnetic resonance (MR) imaging, ultrasonography, and mammography in implant rupture detection and to illustrate pitfalls in MR image interpretation. Thirty patients referred by plastic surgeons with suspected breast implant rupture were prospectively evaluated using MR, ultrasonography, and mammography. Imaging examinations were interpreted independently and blindly for implant rupture and correlated to operative findings. Surgical correlation in 16 patients (53 percent) with 31 implants showed 13 (42 percent) were intact, 5 (16 percent) had severe gel bleed, and 13 (42 percent) were ruptured. MR sensitivity was 100 percent and specificity was 63 percent. Accuracy for rupture was 81 percent with MR, higher than with ultrasonography and mammography (77 and 59 percent, respectively). We describe a specific pitfall in MR interpretation, the "rat-tail" sign, composed of a medial linear extension of silicone along the chest wall. Seen in eight cases (four intact, three ruptures, one gel bleed), the rat-tail sign may lead to misdiagnosis of implant rupture if seen in isolation. Magnetic resonance imaging is more accurate and sensitive than ultrasonography and mammography in detecting breast implant rupture. We describe a new sign (rat-tail sign) composed of medial compression of the implant simulating silicone extrusion as a potential false-positive MR finding for rupture. This article presents clinical experience with magnetic resonance, mammography, and ultrasound in the diagnosis of implant rupture and defines and illustrates potential pitfalls of MR interpretation, including the new rat-tail sign.

Abstract

To assess ultrasonographically (US) guided needle aspiration of breast abscesses as an alternative to surgical incision and drainage or indwelling catheter placement.The authors reviewed hospital records from 1995 to 1997 for patients undergoing US-guided aspiration of breast abscesses. Two radiologists reviewed the US, mammographic, and US-guided aspiration studies for the size, appearance, and drainage of abscesses. The medical records were reviewed for follow-up data.Thirteen patients aged 15-69 years underwent US-guided percutaneous aspiration of 13 breast abscesses. All patients presented with a palpable mass, nine of which were retroareolar. At US, four abscesses were oval, nine (including three with septa) were irregularly shaped, and five had a thick rind. Of seven abscesses 2.4 cm or smaller, two were almost completely drained and five were completely aspirated. All seven abscesses resolved without surgery. Of six women with incompletely aspirated abscesses larger than 2.4 cm (one 3 cm, four 4 cm, one 7 cm), five required surgical referral; one of these cases was referred after repeat aspiration had been performed.Percutaneous aspiration of breast abscesses can enable diagnosis of abscesses and be used to treat small abscesses if they are completely drained. Partial drainage of abscesses larger than 3 cm may be palliative, but incision and drainage still may be necessary for definitive treatment.

Abstract

Radiofrequency (RF) energy applied to breast cancers will result in cancer cell death.Prospective nonrandomized interventional trial.A university hospital tertiary care center.Five women with locally advanced invasive breast cancer, aged 38 to 66 years, who were undergoing surgical resection of their tumor. One patient underwent preoperative chemotherapy and radiation therapy, 3 patients received preoperative chemotherapy, and 1 had no preoperative therapy. All patients completed the study.While patients were under general anesthesia and just before surgical resection, a 15-gauge insulated multiple-needle electrode was inserted into the tumor under sonographic guidance. Radiofrequency energy was applied at a low power by a preset protocol for a period of up to 30 minutes. Only a portion of the tumor was treated to evaluate the zone of RF ablation and the margin between ablated and nonablated tissue. Immediately after RF ablation, the tumor was surgically resected (4 mastectomies, 1 lumpectomy). Pathologic analysis included hematoxylin-eosin staining and enzyme histochemical analysis of cell viability with nicotinamide adenine dinucleotide-diaphorase (NADH-diaphorase) staining of snap-frozen tissue to assess immediate cell death.Cancer cell death as visualized on hematoxylin-eosin-stained paraffin section and NADH-diaphorase cell viability stains.There was evidence of cell death in all patients. Hematoxylin-eosin staining showed complete cell death in 2 patients. In 3 patients there was a heterogeneous pattern of necrotic and normal-appearing cells within the ablated tissue. The ablated zone extended around the RF electrode for a diameter of 0.8 to 1.8 cm. NADH-diaphorase cell viability stains of the ablated tissue showed complete cell death in 4 patients. The fifth patient had a single focus of viable cells (<1 mm) partially lining a cyst. There were no perioperative complications related to RF ablation.Intraoperative RF ablation results in invasive breast cancer cell death. Based on this initial report of the use of RF ablation in breast cancer, this technique merits further investigation as a percutaneous minimally invasive modality for the local treatment of breast cancer.

Abstract

To compare various subjective, empiric, and pharmacokinetic methods for interpreting findings at dynamic magnetic resonance (MR) imaging of the breast.Dynamic spiral breast MR imaging was performed in 52 women suspected of having or with known breast disease. Gadolinium-enhanced images were obtained at 12 locations through the whole breast every 7.8 seconds for 8.5 minutes after bolus injection of contrast material. Time-signal intensity curves from regions of interest corresponding to 57 pathologically proved lesions were analyzed by means of a two-compartment pharmacokinetic model, and the diagnostic performance of various parameters was analyzed.Findings included invasive carcinoma in 17 patients, isolated ductal carcinoma in situ (DCIS) in six, and benign lesions in 34. Although some overlap between carcinomas and benign diagnoses was noted for all parameters, receiver operating characteristic analysis indicated that the exchange rate constant had the greatest overall ability to discriminate benign and malignant disease. The elimination rate constant and washout were the most specific parameters. The exchange rate constant, wash-in, and extrapolation point were the most sensitive parameters. DCIS was not consistently distinguished from benign disease with any method.Dynamic spiral breast MR imaging proved an excellent method with which to collect contrast enhancement data rapidly enough that accurate comparisons can be made between many analytic methods.

Abstract

To evaluate interactive magnetic resonance (MR) imaging-guided preoperative needle localization and hookwire placement in the noncompressed breast in patients in the prone position.Nineteen MR imaging-guided breast lesion localization procedures were performed in 17 patients aged 38-70 years (mean age, 48 years) by using an open-platform breast coil in either a 1.5-T, closed-bore imager (n = 14) or a 0.5-T, open-bore imager (n = 5). Rapid imaging (fast spin-echo, water-selective fast spin-echo, or water-specific three-point Dixon gradient-echo) was alternated with freehand manipulation of an MR-compatible needle to achieve accurate needle placement.Up to three manipulations of the needle were required during an average of 9 minutes to reach the target lesion. MR imaging findings confirmed the final needle position within 9 mm of the target in all cases. The accuracy of 10 localizations was independently corroborated either at mammography or at ultrasonography. Nine lesions were visible on MR images only.Interactive MR imaging-guided, freehand needle localization is simple, accurate, and requires no special stereotactic equipment. Lesions throughout the breast, including those in the anterior part of the breast and those near the chest wall, which can be inaccessible with standard grid or compression-plate techniques, can be localized. A variety of needle trajectories in addition to the horizontal path are possible, including circumareolar approaches and tangential needle paths designed to avoid puncture of implants.

Abstract

Contrast material-enhanced magnetic resonance (MR) imaging is reported to be the most accurate modality for determining the extent of breast cancer before surgery. Three-dimensionally rendered MR images can be used as an adjunct in planning breast surgery. Semiautomated methods are used to isolate the breast tissue within high-resolution MR images and to render the skin with a shaded-surface method. Cut-away views reveal lesions in the interior of the breast. Cut-plane shaded-surface display provides the surgeon with information on the size, extent, and spatial relationships of a breast lesion in a simple, intuitive format. This technique can help the surgeon plan a breast biopsy, lumpectomy, or mastectomy that will maximize local control of breast cancer while minimizing cosmetic damage to the unaffected portions of the breast. In a review of 15 clinical cases, cut-plane shaded-surface rendering aided surgical planning in 10 cases.

Abstract

The purpose of this study was to use information from an established patient tracking system to evaluate patient outcome and assess patient compliance with recommended follow-up after percutaneous breast core biopsy.All breast core biopsies performed from January 1994 through February 14, 1996, that used stereotaxic or sonographic guidance were reviewed. Clinical, imaging, and pathologic findings were correlated with patient outcomes established by recommended surgical and nonsurgical follow-up.Of 160 core biopsies in 153 women, 30 biopsies were performed on the basis of clinical complaints. One hundred thirty lesions were detected by mammography or sonography or both. Of the 70 lesions recommended for surgical excision, 52 (74%) had documented surgical outcomes. Mammographic surveillance was recommended for 90 lesions, of which 10 (11%) had resolved at the time of this study, 49 (54%) were on track toward 3-year lesion stability, 21 (23%) were being followed up elsewhere, four (4%) were lost to physicians, and six (7%) were lost to follow-up for other reasons.Known compliance with follow-up recommendations among these 153 patients who underwent breast core biopsy was higher for patients receiving surgical recommendation (74%) than for patients receiving imaging surveillance recommendation (54%). Problems tracking patients were caused both by loss of patients to follow-up and by incomplete reporting from referring physicians.

Abstract

The purpose of our study was to assess the potential of power Doppler imaging (PDI) to differentiate benign from malignant solid breast masses.Sixty-nine biopsy-proven solid breast masses were evaluated with PDI using 7- to 10-MHz transducers optimized for low-volume flow sensitivity. The extent of flow on PDI was estimated as a percentage of the lesion area on multiple longitudinal and transverse static sonographic images. Flow was categorized as avascular; less than 10%; 10-25%; 25.1-50%; and greater than 50%.Of the 69 lesions evaluated, 33 were malignant and 36 were benign. Of the avascular lesions, nine were malignant and eight were benign. Significant overlap was seen in the vascularity of the other 52 lesions: both malignant and benign lesions revealed a similar range of vascular patterns.Preliminary experience with PDI suggests that both malignant and benign lesions can be avascular and that the presence of color within a solid breast mass is a nonspecific finding. Assessing the extent of vascularity with PDI appears to be of limited value in the diagnostic evaluation of solid breast masses.

Abstract

The authors attempted to determine the accuracy of magnetic resonance (MR) imaging-guided core-needle biopsy performed with a titanium biopsy needle in a breast phantom.Eight 6-7-mm lesions were created at random positions in a lard breast phantom. Each 0.2-mL lesion contained 0.118 mg of gadopentetate dimeglumine, 0.0025 mL of methylene blue dye, and 23.8 mg of gelatin. Rapid fast spin-echo MR imaging was used to guide placement of a 14-gauge titanium core-biopsy needle. A 1.5-T MR imager was used with an open-platform phased-array breast coil.Visualization of blue dye in core specimens confirmed successful biopsy in 16 of 16 attempts. One (n = 13) or two (n = 3) passes through the "skin" of the phantom were necessary for biopsy. The needle trajectory was adjusted less than three times for each pass through the "skin" in 15 of 16 biopsies. Cores that contained lesion material were obtained in the first sample in 15 of 16 biopsies. On T1-weighted images, needles cast 7-mm-diameter artifacts.MR imaging can be used accurately to guide core-needle biopsy of 6-7-mm lesions in a breast phantom.

Abstract

To determine compliance with recommendations for mammographic or surgical follow-up after fine-needle aspiration biopsy of non-palpable breast lesions.The authors reviewed the medical records of 419 patients in whom surgical or mammographic follow-up had been recommended after fine-needle aspiration biopsy. Mammographic, clinical, and follow-up findings were correlated with patient outcome. Of 466 lesions, 395 lesions in 359 patients (age range, 24-89 years; average age, 55 years) were nonpalpable and composed the study.Excisional biopsy was recommended in 141 cases (35.7%) and close-interval mammographic surveillance in 165 (41.8%). Biopsy was performed in 122 (86.5%) of the 141 cases in which it was recommended. Of 165 cases in which follow-up mammography was recommended, 84 (50.9%) were resolved at the close of the study. In the remaining cases, women either did not return (n = 24), were followed up elsewhere or moved (n = 35), were lost to follow-up by their physicians (n = 17), or were lost to follow-up for other reasons (n = 5).Noncompliance with follow-up recommendations is an important issue undermining the benefits of fine-needle aspiration biopsy. Difficulty in tracking patients hinders assessment of patient compliance.

Abstract

Our previous receiver operating characteristic (ROC) study indicated that the detection accuracy of microcalcifications by radiologists is significantly reduced if mammograms are digitized at 0.1 mm x 0.1 mm. Our recent study also showed that detection accuracy by computer decreases as the pixel size increases from 0.035 mm x 0.035 mm. It is evident that very large matrix sizes have to be used for digitizing mammograms in order to preserve the information in the image. Efficient compression techniques will be needed to facilitate communication and archiving of digital mammograms. In this study, we evaluated two compression techniques: full frame discrete cosine transform (DCT) with entropy coding and Laplacian pyramid hierarchical coding (LPHC). The dependence of their efficiency on the compression parameters was investigated. The techniques were compared in terms of the trade-off between the bit rate and the detection accuracy of subtle microcalcifications by an automated detection algorithm. The mean-square errors in the reconstructed images were determined and the visual quality of the error images was examined. It was found that with the LPHC method, the highest compression ratio achieved without a significant degradation in the detectability was 3.6:1. The full frame DCT method with entropy coding provided a higher compression efficiency of 9.6:1 at comparable detection accuracy. The mean-square errors did not correlate with the detection accuracy of the microcalcifications. This study demonstrated the importance of determining the quality of the decompressed images by the specific requirements of the task for which the decompressed images are to be used. Further investigation is needed for selection of optimal compression technique for digital mammograms.

Abstract

Primary squamous cell carcinoma of the breast is a rare cancer. Published reports of prognosis are variable, and most studies are case reports of one or a few patients. We report an additional case of squamous cell carcinoma of the breast occurring in a 53-year-old black woman. In reviewing the reported cases of this tumor over the past 20 years, we compared features of this cancer with those of the more common breast adenocarcinoma with squamous metaplasia. When squamous cell carcinoma of the breast is encountered, a skin primary lesion and metastasis from a distant site should be excluded. Prognosis is determined largely by stage and does not differ significantly from the prognosis in breast adenocarcinoma with squamous metaplasia.

Abstract

To prospectively evaluate the efficacy of ultrasonography in the diagnosis of ruptured silicone gel breast implants, 98 patients (192 implants) underwent preoperative breast ultrasonography prior to silicone gel breast implant removal. The prevalence of implant rupture confirmed at surgery in this group of patients was 62 of the 192 implants (32 percent). Of the 60 implants diagnosed as ruptured by ultrasonography, 46 were confirmed as having visible defects at surgery (true positive) for a positive predictive value of 77 percent. Of the 132 implants diagnosed as intact by ultrasonography, 116 were confirmed as intact at surgery (true negative) for a negative predictive value of 88 percent. Overall, the sensitivity of ultrasonography for implant rupture was 74 percent, and the specificity was 89 percent. These findings demonstrate that ultrasonography is an effective imaging modality for the diagnosis of silicone gel breast implant rupture. Compared with mammography, ultrasonography appears to offer superior sensitivity and specificity without radiation exposure or discomfort. Although magnetic resonance imaging has shown considerable promise in the diagnosis of implant rupture, ultrasonography provides comparable sensitivity at a fraction of MRI's cost.

Abstract

To evaluate axillary lymph node dissection done without closed drainage in conjunction with breast conservation cancer surgery.Prospective clinical study.Two university hospitals.Eighty-one women undergoing wide local excision of breast cancer with simultaneous or subsequent axillary lymph node dissection.No axillary drain was placed following axillary lymphadenectomy.The development and resorption of axillary seroma fluid as measured by clinical aspiration and serial sonographic examination.Thirty-four (42%) of the 81 women required axillary seroma aspiration even though axillary fluid was present in 92% (22/24) of those studied sonographically. The seromas accumulated over the first 2 weeks following axillary dissection and resorbed over the next 2 weeks, as assessed by both clinical and sonographic examination. The complication rate was 2% (2/81). The surgery was performed safely on an outpatient or short-stay basis in 99% (80/81) of patients. All patients except one were discharged within 23 hours of surgery, and 56 patients were discharged directly after anesthesia.Axillary lymph node dissection done in conjunction with breast conservation surgery can be performed in an ambulatory or short-stay setting without axillary drainage. Postoperative seromas will resolve within 1 month, and fewer than half will require aspiration. Lymphadenectomy without drainage reduces morbidity and allows the patient greater personal comfort.

Abstract

We have developed a computerized method for detection of microcalcifications on digitized mammograms. The program has achieved an accuracy that can detect subtle microcalcifications which may potentially be missed by radiologists. In this study, we evaluated the dependence of the detection accuracy on the pixel size and pixel depth of the digitized mammograms. The mammograms were digitized with a laser film scanner at a pixel size of 0.035 mm x0.035 mm and 12-bit gray levels. Digitization with larger pixel sizes or fewer number of bits was simulated by averaging adjacent pixels or by eliminating the least significant bits, respectively. The SNR enhancement filter and the signal-extraction criteria in the computer program were adjusted to maximize the accuracy of signal detection for each pixel size. The overall detection accuracy was compared using the free response receiver operating characteristic curves. The results indicate that the detection accuracy decreases significantly as the pixel size increases from 0.035 mm x 0.035 mm to 0.07 mm x 0.07 mm (P < 0.007) and from 0.07 mm x 0.07 mm to 0.105 mm x 0.105 mm (P < 0.002). The detection accuracy is essentially independent of pixel depth from 12 to 9 bits and decreases significantly (P < 0.003) from 9 to 8 bits; a rapid decrease is observed as the pixel depth decreases further from 8 to 7 bits (P < 0.03) or from 7 to 6 bits (P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Abstract

To correlate the range of clinical presentations with mammographic and histologic findings in patients with Paget disease of the nipple.The clinical, pathologic, and mammographic records of 58 patients who had biopsy-proved Paget disease of the nipple were retrospectively reviewed. The results of two previous studies were also included.Among 34 patients who had typical findings of Paget disease, the mammograms of 17 (50%) showed normal findings, those of 10 (29%) showed nipple, areolar, or subareolar abnormalities, and those of seven (21%) showed evidence of masses or calcifications. Of the mammograms of 24 women with Paget disease but without clinical findings, 19 (79%) showed evidence of suspicious masses or calcifications, four (17%) showed nipple or areolar abnormalities, and one was negative.Nonspecific findings of nipple-areolar complex thickening should be correlated with findings at breast physical examination to confirm or exclude Paget disease.

Abstract

Prospective sonographic evaluation of 44 Achilles tendons in 22 patients with heterozygous familial hypercholesterolemia (FH) was performed with linear-array transducers with high frequency and high resolution. Intratendinous hypoechoic regions believed to represent xanthomas, ranging from single hypoechoic nodules to diffusely enlarged tendons that were heterogeneously hypoechoic, were seen in 40 of the 44 tendons (91%) and 21 of the 22 patients (95%). In addition, focal xanthomas were seen in two of three patients whose Achilles tendons were either normal or questionably abnormal at palpation. The direct visualization of xanthomas in most of these patients contrasts with findings from previously published studies, in which sonographically detected involvement was based on secondary tendon enlargement alone. The improved sonographic visualization of tendon xanthomas in FH, rather than the secondary tendon enlargement caused by them, therefore, suggests a new role for ultrasound in the early diagnosis and follow-up of these cases.

Abstract

The purpose of this study was to describe and illustrate the sonographic appearances of 19 ruptured silicone gel breast implants.We retrospectively reviewed the sonograms of 16 patients with 19 ruptured silicone gel implants from two institutions. The ruptured implant was confirmed at surgery in 17 cases and by mammographic and clinical findings of a ruptured implant combined with biopsy findings of a silicone granuloma in two cases. Breast sonograms were available for review in all patients. The clinical presentation of each patient was recorded. The sonograms and mammograms were reviewed, and the findings were correlated with the surgical findings. In 16 of the 19 ruptured implants, mammographic findings suggested rupture, including lobulation of the contour of the implant and/or silicone extrusion into the breast parenchyma or axilla. In two ruptured implants, mammographic findings were normal, and in one case, no mammogram was available. In those three patients, palpable masses and clinical findings were suggestive of rupture.Sonography showed a unique echogenic appearance called echo-dense noise, in 17 of the 19 ruptured implants; in 10 of the 17, sonograms showed hypoechoic masses of extruded silicone also. In two ruptured implants, sonograms showed only the hypoechoic masses of extruded silicone gel.Our experience suggests that echogenic noise is a unique sonographic sign of ruptured silicone gel breast implants and may be caused by phase aberration related to the speed of sound being slower in silicone than in soft tissue.

Abstract

Our purpose was to determine the mammographic/galactographic features of solitary breast papillomas and to correlate these features with the pathologic findings.Retrospective review of pathology files revealed 72 women in whom breast biopsy reports described a solitary papilloma. All patients with additional pathologic abnormalities were excluded from this study. Patients meeting the pathologic criteria and for whom mammograms, galactograms, or both were available and had been obtained within 6 months before biopsy were included. Twenty-four women met these criteria and form the basis of this study. Presenting clinical signs and symptoms were reviewed. Abnormal mammographic/galactographic findings were correlated with pathologic features.Nipple discharge was present in 21 (88%) of 24 patients, two (8%) of 24 patients had abnormal findings on screening mammography, and one patient had a palpable mass that was visible on mammograms. Eight (42%) of 19 mammograms had abnormal findings, including dilated duct(s) in five cases (26%), nodules in two cases (11%), and microcalcifications in one case (5%). All technically adequate galactograms (13/15) had abnormal findings, with 12 (92%) of 13 showing an intraluminal filling defect. The other technically adequate galactogram (8%) showed only a solitary obstructed duct. Ductal dilatation was greatest at or central to the papilloma on 12 (92%) of 13 galactograms. Imaging features correlated well with the histologic findings.Patients with solitary papillomas most commonly have nipple discharge, normal mammographic findings, and a galactographic filling defect. Galactography is useful for localizing papillomas.

Abstract

Interval carcinoma is the term used to describe malignant breast tumors that are detected in the intervals between mammographic screenings. These tumors are important because they contribute significantly to breast cancer mortality in the screened population.Two radiologists retrospectively reviewed the mammograms of the 96 interval carcinomas (17% of all malignant neoplasms in the screened group) that were detected during the 10-year Malmö Mammographic Screening Trial in Malmö, Sweden (average time between screenings, 21 months), including one sarcoma, 75 invasive carcinomas, and 20 noninvasive carcinomas. We recorded the interval between screening and detection, and noted the tumor's appearance on the prior screening mammogram and at the time of diagnosis; these data were correlated with histologic tumor type and the patients' mortality. The doubling time for tumor volume of the invasive carcinomas was estimated.Excluding the sarcoma, 72 carcinomas (75%) were detected within 18 months of screening. Retrospective review of the available preceding screening mammograms (94 cases) indicated that 10 tumors were missed (observer's error), 63 studies showed no tumor (true interval carcinomas), and 21 studies showed subtle signs of malignancy, mostly nonspecific densities or asymmetries (unrecognized sign). Of 66 invasive carcinomas in which doubling times for tumor volume could be calculated, 27 (41%) had doubling times of less than 100 days. At the end of the study, 20 of the 96 patients had died of breast cancer.Interval carcinomas in this series were dominated by comedo, medullary, and mucinous carcinomas that often had a nonspecific appearance (when present) on prior screening mammograms. The interval carcinomas also contained a subset of rapidly growing tumors with a grave prognosis.

Abstract

Prior studies have suggested that the recurrence rate is lower in breast cysts treated by pneumocystography (injection of air into cyst cavities after cyst aspiration) than in cysts treated by fine-needle aspiration alone. To determine if this is the case for impalpable breast cysts, we reviewed the hospital records and mammograms of 38 women with 41 impalpable cysts. Mammograms obtained immediately after aspiration show that pneumocystography was successful in 18 and unsuccessful in 20 of the 41 cysts. Four cysts were excluded from the study: one cyst that recurred after aspiration and was sampled by biopsy and three cysts for which immediate post-aspiration mammograms were unavailable but which had recurred or persisted 3 years after aspiration. Review of follow-up mammograms made 4 months to 3 years after the aspiration showed that three (17%) of 18 cysts in the group with successful pneumocystography recurred and 11 (58%) of 19 cysts in the unsuccessful group recurred (p = .02). No difference was found in the number of recurrent cysts in relation to estrogen therapy or menopausal status. Our results indicate that impalpable breast cysts treated by pneumocystography are less likely to recur than are cysts treated by aspiration alone.

Abstract

The mammographic features of fibrosarcoma of the breast, a rare malignant tumor, have not been described. Accordingly, we reviewed the mammograms, pathology reports, and medical records of five women with this tumor. All cases had surgical biopsies and a diagnosis made by histologic evaluation. The age of the patients ranged from 48 to 79 years. Histologically, three of the five fibrosarcomas were thought to have arisen from phyllodes tumor, and four were palpable. On mammograms, the tumors were dense masses with largely indistinct margins, ranging from 1.5 to 7.0 cm in diameter. One contained calcified osseous elements suggesting osseous trabeculae. Although the osseous trabeculae in that tumor strongly suggested sarcoma, most of the tumors had a nonspecific appearance on mammograms. Fibrosarcomas of the breast have a nonspecific mammographic appearance. Surgical biopsy and histologic evaluation are necessary for definitive diagnosis.

Abstract

A prospective study of the immediate complications of 370 consecutive breast-imaging procedures (203 wire localizations and 167 radiographically or sonographically guided fine-needle aspirations) is reported. Vasovagal reactions occurred in 27 (7%) of 370 cases, ranging in severity from syncope (four of 370, 1%) to mild light-headedness. These vasovagal reactions were independent of procedure type or use of local anesthesia, but were more common in younger patients. Other complications included prolonged (5 min or longer) bleeding (three of 370, 1%) and extreme pain (two of 370, 1%). One patient was found to have malignant hypertension. We conclude that wire localizations and imaging-guided aspirations are generally well tolerated procedures. However, vasovagal reactions are frequent enough to warrant close observation of patients. Radiologists and breast-imaging personnel should be able to recognize and treat vasovagal reactions.

Abstract

Ultrasound examinations of solid breast masses were reviewed retrospectively to determine whether quantitative data of their dimensions could distinguish benign from malignant tumors. Forty-nine fibroadenomas and 30 carcinomas with cytologic or histologic proof were identified. No significant difference was found between carcinomas and fibroadenomas when comparing the average ratio of length to anteroposterior (L/AP) diameter or the mean ratio of anteroposterior diameter to transverse diameter (AP/T). In this limited series, quantification of the degree of mass elongation along the natural breast tissue planes had low sensitivity in distinguishing malignant from benign tumors.

Abstract

The mammograms and histologic slides of 58 cases of atypical hyperplasia (AH) of the breast were retrospectively reviewed to determine the geographic correlation (direct, near, or remote) between mammographic abnormalities (if present) and the histologic findings. A direct mammographic-histologic correlation was found in 24 of the 58 cases (41%), near correlation in 15 (26%), and remote correlation in 19 (33%). Clustered microcalcifications were the most common mammographic abnormality that was directly correlated with AH at histologic examination. Atypical ductal hyperplasia was much more frequently associated with a direct mammographic-histologic correlation than was atypical lobular hyperplasia (48% vs 9%). The authors conclude that, although no pathognomonic appearance of AH was discovered, mammographic abnormalities similar to those of small cancers could be directly correlated with histologic findings in 41% of cases. Since AH has been shown to be associated with a five- to tenfold increased risk of subsequent invasive carcinoma, frequent clinical and at least yearly mammographic follow-up is suggested once AH is discovered.

Abstract

The authors present the clinical, mammographic, and pathologic findings in seven patients with radial sclerosing lesions (RSLs) who had a nonpalpable stellate lesion at mammography. Although the radiographic findings were suggestive of RSL in six of seven patients, diagnostic excisional biopsy was recommended for all. One RSL had associated microcalcifications localized in contiguous adenosis. The authors did not find this a useful criterion to differentiate RSL from carcinoma. Similarly, the presence of either a lucent or dense central core was not radiographically diagnostic. Surgical excision of these stellate lesions is therefore required.

Abstract

The increased risk of a second malignant neoplasm developing after treatment for Hodgkin disease is well documented. Subsequent development of breast cancer in women who have been treated for Hodgkin disease is a relatively rare association. To date, no reports of the mammographic detection of breast cancer in this group of women have been published. We report six patients who developed seven breast cancers after treatment for Hodgkin disease. The average age of the women at the time of diagnosis of breast cancer was 33.5 years; diagnosis was made 10-23 years after treatment. There appears to be an increased prevalence of breast carcinoma in women who have been treated for Hodgkin disease. This association should receive further study to evaluate appropriate modifications in routine breast cancer screening for these women.

Abstract

Radiography of specimens is an essential step in confirming excision of nonpalpable breast lesions. On occasion, however, the pathologist may not identify the lesion histologically. The authors report five cases in which suspicious microcalcifications were included in the excised tissue but were not identified by the pathologist. In all five, paraffin tissue block radiography enabled identification of the specific blocks containing the microcalcifications. The correct tissue blocks were then sectioned again, and the microcalcifications were identified histopathologically. In one case, the initial diagnosis of intraductal hyperplasia was changed to intraductal carcinoma with focal invasion. When the pathologist cannot identify the calcifications on initial histopathologic sections, this technique may assist in identification of the mammographic abnormality.

Abstract

We retrospectively reviewed the imaging studies in 17 proved cases of primary aldosteronism to determine the value of the procedures used to detect adrenal tumors or adrenal hyperplasia. The procedures included CT with 3-, 5-, and/or 10-mm-thick sections (17 patients), 131I-6 beta-iodomethyl-19-norcholesterol (NP-59) scintigraphy (16 patients), and MR imaging (six patients). Proof of the adrenal abnormality was established in cases of tumor (seven adenomas, one carcinoma) by surgery and in cases of adrenal hyperplasia by surgery (three cases); venous sampling (three cases); or combined clinical, biochemical, and imaging data (three cases). Both CT and scintigraphy detected six of the seven adenomas and the adrenal carcinoma (88%). Regarding hyperplasia, CT was correct in five of six and scintigraphy was correct in two of four cases proved by surgery or venous sampling. CT and NP-59 were concordant and suggested the diagnosis of hyperplasia in the remaining three cases without surgical or venous sampling proof. MR detected both cases of adenoma in which it was performed and showed evidence of hyperplasia in one of the four cases of hyperplasia in which it was performed. Although the number of patients in this series is too small to have much statistical power, these results suggest that CT and NP-59 scintigraphy are equivalent in the detection of adrenal abnormalities in patients with primary aldosteronism. The value of MR in the detection of small adrenal contour abnormalities was limited by slice thickness capabilities.

Abstract

To compare the advantages of one-view versus two-view second-screening (follow-up) mammography, oblique and craniocaudal projection mammograms from 1,000 consecutive asymptomatic women who had prior normal baseline studies were reviewed retrospectively, first with only the oblique images, then with the oblique and craniocaudal views. In women with dense breasts, one-view (oblique only) readings resulted in abnormal interpretations four times more frequently (53 cases, 5.3%) than two-view readings (13 cases, 1.3%). The induced cost from these abnormal interpretations would have more than offset the small savings in operating expense associated with one-view screening. In contrast, four times fewer abnormal one-view interpretations (13 cases, 1.3%) were made in women with primarily fatty breasts, in whom superimposition of dense tissue on images is not as frequently a problem. In these women, considering only cost, it may be reasonable to obtain a single mediolateral oblique projection for follow-up screening mammography. However, the issue of whether to implement such an approach remains unresolved, because the sensitivity of one-view versus two-view second screening in the detection of breast cancer has not yet been determined.

Abstract

Replacement of 7-azatryptophan for tryptophan in two positions on the catalytic chain of aspartate transcarbamylase results in changes in the enzyme's homotropic and heterotropic interactions although there is no change in the enzyme's specific activity. The extent of azatryptophan incorporation was quantitated by amino acid analysis which showed that 85% of the tryptophan residues had been replaced. The substituted enzyme is activated by ATP and inhibited by CTP to a greater extent than is the native enzyme. The aspartate saturation curve in the presence of ATP is identical for the two enzymes, but the curve in the presence of CTP and without effectors is shifted toward higher aspartate concentrations for the azatryptophan-substituted enzyme. At low aspartate concentrations, the native enzyme is activated to a greater extent by the substrate analog succinate. These data suggest that the substitution renders the low substrate affinity conformational state of the enzyme less catalytically efficient. This interpretation is in agreement with possible side chain interactions observed in the three-dimensional structure of the enzyme.